Optimizing Endocrinology Prior Authorizations with Epic Orchestrate

Klivira's platform integrates seamlessly to enhance endocrinology Epic Orchestrate workflows, transforming prior authorization from a bottleneck into an efficient, embedded process for high-volume medications and devices.

Revenue cycle directors and prior authorization coordinators in endocrinology face unique challenges with the increasing volume and complexity of prior authorizations for critical medications and devices. Leveraging Epic Orchestrate's native workflow capabilities, Klivira provides a robust solution to automate and accelerate PA processes directly within the EMR, reducing administrative burden and improving patient access to care.

The Prior Authorization Burden in Endocrinology

Endocrinology practices manage a high volume of prior authorizations for essential therapies, including GLP-1 agonists, CGMs, insulin pumps, and growth hormone. The variability in payer criteria, frequent policy changes, and extensive documentation requirements often lead to delays and denials. This administrative load diverts clinical staff from patient care and impacts revenue cycles.

Key Endocrinology PA Triggers Requiring Orchestration

GLP-1 receptor agonists (e.g., Ozempic, Mounjaro, Zepbound) for T2D and obesity, with diverse step therapy and BMI criteria.
Continuous Glucose Monitoring (CGM) systems (e.g., Dexcom G7, FreeStyle Libre 3) requiring specific diabetes diagnosis and insulin-use documentation.
Insulin pumps and tubeless systems (e.g., Tandem t:slim X2, Omnipod 5) often linked with CGM for hybrid closed-loop systems, demanding detailed adherence records.
SGLT2 inhibitors (e.g., Jardiance, Farxiga) for T2D, heart failure, and CKD, each with distinct PA criteria.
Growth hormone therapy (e.g., somatropin biosimilars) necessitating diagnostic and IGF-1 level documentation.

Leveraging Epic Orchestrate for Integrated PA Workflows

Epic Orchestrate, an Epic-native workflow surface, allows for the placement of SMART on FHIR applications directly within Hyperdrive, embedding critical functions where clinicians work. Klivira integrates with Orchestrate to surface prior authorization tasks, required documentation prompts, and real-time status updates within the physician's or PA coordinator's native Epic workflow. This eliminates context switching and streamlines the initiation and management of PAs for endocrinology treatments.

Streamlining Documentation and Adherence to Clinical Guidelines

Endocrinology PAs are heavily governed by clinical practice guidelines such as the ADA Standards of Care, AACE Clinical Practice Guidelines, and ATA Guidelines. Klivira's platform, integrated with Epic Orchestrate, guides users through the precise documentation required, including A1c levels, prior medication trials, BMI criteria, and ejection fractions. This ensures that submitted authorization requests meet payer-specific criteria and align with evidence-based clinical standards, reducing common denial reasons like incomplete patient compliance documentation or missing step therapy evidence.

Klivira's Role in Automating Endocrinology PA through Epic Orchestrate

Klivira extends the power of Epic Orchestrate by providing intelligent automation for endocrinology prior authorizations. Our solution incorporates ADA/AACE-guideline-aware step-therapy logic, manages GLP-1 indication-specific routing (T2D vs. obesity), and automates CGM and insulin pump re-authorization workflows. By tracking payer-specific obesity benefit status and biosimilar substitution requirements, Klivira ensures that prior authorization submissions are accurate and aligned with the latest payer policies, reducing manual effort and improving approval rates.

Addressing Common Denial Reasons with Orchestrated Automation

**GLP-1 Obesity-Indication Coverage Gaps:** Klivira tracks payer-specific coverage and criteria, alerting staff to potential issues upfront.
**Step Therapy Requirements:** Automated checks ensure compliance with required metformin trials or first-line GLP-1 trials.
**CGM Denial for Non-Insulin-Requiring T2D:** Proactive validation against payer criteria prevents unnecessary submissions.
**Biosimilar Substitution:** The platform guides appropriate biosimilar selection based on formulary tiers and payer mandates.
**BMI Criteria:** Automated validation of BMI and comorbidity documentation for obesity-related medications.

Frequently asked questions

How does Epic Orchestrate help with GLP-1 prior authorizations in endocrinology?

Epic Orchestrate, combined with Klivira, embeds the entire GLP-1 PA workflow directly into Epic. This means clinicians can initiate and track authorizations for medications like Ozempic or Mounjaro, respond to documentation requests, and view real-time status updates without leaving their native Epic environment, streamlining a high-volume process.

Can Klivira integrate CGM re-authorizations into Epic Orchestrate workflows?

Yes, Klivira automates the periodic re-authorization cycles for CGMs (e.g., Dexcom G7, FreeStyle Libre 3). Through Epic Orchestrate, the system can prompt for required adherence documentation and facilitate the re-submission process, ensuring continuous coverage for patients with diabetes.

What documentation is typically required for insulin pump PAs via Orchestrate?

For insulin pump prior authorizations, Klivira, through Epic Orchestrate, will guide the collection of documentation such as diabetes diagnosis with insulin requirement, evidence of a prior MDI trial, and patient training and adherence records. This structured approach ensures all payer criteria are met for devices like the Tandem t:slim X2 or Omnipod 5.

How does Klivira handle step therapy requirements for endocrinology medications within Epic Orchestrate?

Klivira's platform integrates step therapy logic based on ADA/AACE guidelines and specific payer policies. When a PA is initiated via Epic Orchestrate, the system automatically verifies if prior medication trials (e.g., metformin before a GLP-1) have been documented, flagging any non-compliance before submission to prevent denials.

Does Klivira support obesity medication PA criteria within Epic Orchestrate?

Yes, Klivira tracks the highly variable payer-specific coverage for anti-obesity medications like Zepbound or Wegovy. Within Epic Orchestrate, the system prompts for necessary documentation such as BMI thresholds, comorbidities, and prior weight-management interventions, ensuring submissions align with the current, often restrictive, payer policies.